Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | RDA56826 | CA |
NPI | 1366094112 |
---|---|
Provider Name | Alma Evelia Velasquez |
First Address | El Monte, CA 91732-2321 |
Second Address | Baldwin Park, CA 91706-3163 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2019 |
Last Update Date | 11/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RDA5686 | (05) | CA |